Welcome to our next installment in So You Want to Be. In this series, we highlight a specific specialty within medicine, such as ophthalmology, and help you decide if it’s a good fit for you. You can find the other specialties here. A lot of you asked for ophthalmology, so that’s what we’re covering here.
If you’d like to see what being an ophthalmologist looks like, check out my personal YouTube channel, Kevin Jubbal, M.D., where I do a second series in parallel called a Day in the Life. Once the world is back to a more normal baseline, we’ll be doing a Day in the Life of an Ophthalmologist.
So you want to be an ophthalmologist. You like the idea of exploring a fascinating organ and helping patients save their vision. Let’s debunk the public perception myths of what it means to be an ophthalmologist, and give it to you straight. This is the reality of ophthalmology.
What is Ophthalmology?
Ophthalmology is the medical and surgical specialty dealing with ocular and orbital diseases – pretty much anything relating to the eyes and immediate surrounding structures. Ophtho is unique in that it isn’t a strictly medical or surgical field, but rather a blend. The practice of ophthalmology can be categorized into three main areas: medical, procedural, and surgical.
There are many diseases that are unique to the eye, but also several systemic diseases that have manifestations in the eye. Within the medical focus of ophthalmology, there are 5 main categories:
First, infectious. Infectious diseases of the eye can be viral, bacterial, fungal, or parasitic in nature. These include STI’s like syphilis, chlamydia, and gonorrhea, to fungi like candida, to parasites like toxoplasmosis or the worm causing river blindness, Onchocerca volvulus.
These infections may be confined to the eye, but may also be systemic yet manifest in the eye. For example, with syphilis, a patient may only recognize the ocular symptoms, such that the ophthalmologist is the first person to diagnose the patient with a systemic infection.
Next, systemic inflammatory diseases can cause uveitis, or inflammation in the eye. These diseases are wide and varied, from rheumatoid arthritis and lupus to inflammatory bowel disease and sarcoidosis.
Diabetic retinopathy occurs in patients with poorly controlled diabetes. In short, the small vessels get damaged, which we call microvascular damage, resulting in scarring, bleeding, retinal detachments, and can even cause blindness. This is the leading cause of vision loss worldwide.
Believe it or not, you can get tumors in your eye. This can be retinoblastoma, which is screened for in newborns, choroidal melanoma, which is actually not directly related to skin cancer, or primary intraocular lymphoma.
The eye and orbit are a common site of metastases for other cancers, meaning a primary cancer releases cells in the bloodstream that take hold in the eye. It makes sense, as the eye has the highest rate of blood flow per weight compared to any tissue in the body.
Prescription and recreational drugs can both cause long term damage to the eyes. For example, chronic alcoholism may result in vitamin deficiency leading to vision issues. Alternatively, methanol should never be ingested, as it causes optic nerve delamination which can result in blindness.
Glaucoma has two main types, acute angle closure and primary open angle. Both can lead to damage to the optic nerve and irreversible vision loss. Open-angle glaucoma is the leading cause of irreversible blindness worldwide, and is called the “silent thief” as it slowly causes vision loss overtime without patients being aware.
Ophthalmology has a variety of procedures, which one wouldn’t necessarily consider surgical, as these are performed in the office, not the operating room.
The way lasers are used in the field is almost science fiction. A laser retinopexy is essentially spot welding to prevent retinal detachment. This is used to treat retinal tears. For acute angle closure glaucoma, which is highly urgent as it can cause rapid vision loss, a laser peripheral iridotomy is used to create a hole in the iris and reduce pressure.
Eye injections are also performed, such as anti-VEGF for treatment of diabetic retinopathy and macular degeneration. In a similar vein, a diagnostic tap and inject is where the ophthalmologist gets fluid from the eye and then injects antibiotics or antivirals through the same needle.
Lastly, ophthalmologists sometimes perform lesion removal and excision, like when I got my chalazion drained.
When it comes to surgical procedures in the operating room, ophthalmologists can perform either extraocular or periocular cases, meaning those that are outside and around the eye, or intraocular surgeries, meaning within the eye.
Orbital surgery includes excision, debulking, or taking biopsies of masses and lesions in the orbit.
Reconstructive surgery around the eye can be done after trauma, like a baseball to the orbit, or after extensive surgery, such as after a cancer resection.
Restorative or cosmetic surgeries include eyelid surgery for ptosis, meaning droopy eyelids, or having excess skin over the eye.
Strabismus surgery is concerned with the actual eye muscles to help bring the eyes into proper alignment.
In terms of intraocular surgery, there are four main ones.
First, cataract surgery is the bread and butter for general ophthalmologists, and is the most common outpatient surgery, with 3 million surgeries performed every year in the U.S. It makes sense since cataracts are the leading cause of vision loss in the world and everyone gets it, assuming they live long enough.
Phacoemulsification is the technique used, whereby ultrasound technology breaks up the cataracts and a vacuum sucks it out. An artificial lens is placed in the eye with specifications unique to that individual’s refractive error.
Second, cornea surgery, including corneal transplants. Corneal surgery also includes LASIK or PRK, another form of laser eye surgery that isn’t as well known as LASIK.
Third, glaucoma surgery, which includes placing tiny tube shunts or performing trabeculectomies to redirect flow of the fluid in the eye.
And lastly, retinal surgery, which includes repairing retinal detachments, macular hole repairs, removing foreign bodies within the eyeball, and even lens removal following a complicated cataract surgery.
How to Become an Ophthalmologist
After completing medical school, ophthalmology residency is 4 years, with the first year historically being a transitional or preliminary year, meaning you wouldn’t actually start ophthalmology training until your second year. However, more residency programs are integrating the first year so that you will get some ophthalmology exposure even as an intern.
In terms of competitiveness, ophthalmology is misunderstood as being far more competitive than it really is, in part because it participates in the SF Match rather than the traditional NRMP. In terms of match rate, in the last few years, official data range from 86-89 percent for US graduates. The higher than the usual number of international applicants deflates the overall match rate, making it seem more daunting than it truly is. USMLE data is not reported by Step 1 and Step 2, but rather as a combination of both scores. Parsing this data, Step 1 averages are likely around 240 and Step 2 averages are likely around 250. If you’re considering ophthalmology, this is great news, as the data shows it’s far more attainable than the popular narrative would have you think.
That isn’t to say it’s easy to get into. You’ll still need to be an above-average student. As with any other specialty, having publications, strong letters of recommendation, and good Step scores go a long way in helping your chances. Going to a US allopathic, meaning MD school, is much more advantageous compared to attending an osteopathic, meaning DO, or international medical school. If you graduate from an osteopathic or international medical school, expect an uphill battle, with official match rate data around 20-40% for these students rather than high 80’s for your US allopathic counterparts.
Medical students that end up applying to ophthalmology are usually those who understand the importance of a good lifestyle. Outside of ophthalmology, the stereotype is that they’re myopic nerds who are fascinated by a small organ, or that they’re huge introverts or cannot handle real surgery. Obviously, stereotypes aren’t quite true.
Subspecialties within Ophthalmology
After completing residency, you can choose to subspecialize further with a fellowship, most of which last 1 year, except for surgical retinal and oculoplastics which are two years.
Cornea deals with surgical and medical management of corneal eye diseases and includes refractive procedures like LASIK, PRK, and SMILE, which is essentially an even less invasive option than LASIK.
Surgical retina is a 2-year fellowship, primarily focused on retinal diseases from diabetic retinopathy and retinal detachments. Compared to other subspecialties, the lifestyle is not as optimal, as there are occasional emergent add-on cases, like retinal detachments, but even these can generally wait until the next morning.
Medical retina is a 1-year fellowship dealing with medical management of similar retinal diseases. You’ll be performing lasers and injections, but no retinal surgeries.
Glaucoma fellowship will have you trained in medication, lasers, and surgery to decrease intraocular pressure.
Oculoplastics is a 2-year fellowship dealing with orbital diseases and adnexal structures such as the eyelids, tear drainage system, and the face. It includes both aesthetic and reconstructive surgeries.
Pediatric & Strabismus
With a pediatric fellowship, you’ll deal with all ocular issues that children have, ranging from glaucoma to retinopathy of prematurity, meaning abnormal blood vessel development in the retina in premature babies. However, your bread and butter will primarily be refractive errors, amblyopia, and strabismus, meaning the misalignment of the eyes. Amblyopia is when the visual pathways in the brain are not developed properly due to poor visual input, such as from strabismus or refractive error, and this can result in permanent vision issues in children if not properly corrected before age 7.
Neuro-ophthalmology is concerned with how the nervous system relates to the eye and vision, meaning you’ll be dealing with optic neuritis, optic neuropathy, double vision, and paralysis or spasms around the eye.
Ocular oncology is an evolving field dealing with primary and metastatic tumors of the eye and orbit. You’ll be working closely with oncologists, radiation oncologists, and dermatologists.
Completing a uveitis fellowship makes you the specialist for infectious and inflammatory disease in the eye, particularly those of the uvea, which is at the front of the eye, more specifically the iris, choroid, and ciliary body.
What You’ll Love About Ophthalmology
Ophthalmology is unique in that it combines medicine, office procedures, and surgery into one practice. It’s also a highly innovative field with cutting edge technology. For example, Ocular Coherence Tomography, or OCT, uses near-infrared technology to produce cross-sectional pictures of a patient’s retina, visualizing each layer independently and measuring their thickness.
In terms of lifestyle, it’s hard to beat. You won’t have to come in on weekends, and if you’re on call, it’s generally light. For the most part, you’re working a regular 8 to 5 job. Compensation amongst physicians is in the upper third, with an average salary of $366,000 per year. As a procedural specialty, compensation is largely a function of how many procedures you perform. If you can increase efficiency and do an extra few cataract surgeries in a given morning, your compensation will reflect that. The lifestyle is phenomenal as an attending, and compared to other residencies, particularly surgical, ophthalmology is far more laid back.
Ophthalmology is also unique in that it’s a highly visual field – no pun intended. A great deal of your diagnosis will depend on your exam. It’s one of the few fields remaining where the physical exam is vital, and being able to diagnose a patient from a physical can be gratifying.
Lastly, you’ll be highly specialized in a very specific area. Many systemic health issues manifest in the eye, so there will be times that you’re the first physician to catch an infectious disease or even cancer. Because of your high degree of specialization, you may even catch important findings on imaging that even radiologists may miss.
One example that comes to mind is a teenager with trauma to the eye during a sporting event resulting in a fracture to his orbital floor. The inferior rectus muscle of his eye was entrapped by the fracture, so that when he tried to look up, not only was he restricted, but he has a drop in heart rate, known as the oculocardiac reflex. This happens because the eye muscle contains sensory nerves from the ophthalmic division of the trigeminal nerve. When the entrapped muscle tries to move, these nerves can become activated, which then synapse on the vagus nerve, resulting in bradycardia, or a slower heart rate.
What You Won’t Love About Ophthalmology
The flip side of being so highly specialized and independent is that you may feel more isolated compared to other specialists. Whereas most of medicine is moving towards incorporating teams, you won’t be as deeply involved in coordinated care as an ophthalmologist, apart from the occasional consult to rheumatology, neurology, endocrine, and of course the patient’s PCP.
There’s also a steeper learning curve in residency, as much of ophtho is not emphasized in medical school. You’ll be doing new imaging, a new, more detailed physical exam, and learning about pathologies that weren’t highlighted in medical school.
Depending on your personality, you may not like the rapid change in the field – you must be willing to adapt. For example, up until the 1980s, extracapsular cataract surgery was the most common type of cataract surgery performed. However, in the late ’80s and ’90s, phacoemulsification, whereby ultrasound is used to break up the lens, took over for a variety of reasons. Some ophthalmologists, particularly the older ones, were unable to adapt to the new standard and simply stopped performing the procedures.
Additionally, if you want to work in more desirable locations, such as a larger city, you will probably need to specialize, as it’s more difficult to be a general ophthalmologist in dense metropolitan areas.
Lastly, ophthalmologists feel that there is increasing encroachment from optometrists. This isn’t an uncommon theme in medicine, which we’ll discuss further on this channel. Optometrists are essential providers in eye care and are at the front lines for a great majority of eye diseases, and do plenty to earn their OD. However, in many states, optometry organizations are pushing to increase the scope of practice to include laser procedures, small surgeries, injections, and medications which are typically safer in the hands of more extensively trained ophthalmologists. It’s not a “us versus them” mentality, but rather we must think of what is best and safest for the patient.
Should You Become an Ophthalmologist?
How can you decide if ophthalmology is the right field for you?
The stereotype is that if you’re an introverted nerd that prefers geeking out alone over working in teams, ophtho may be a good fit. But in actuality, anyone can be an ophthalmologist and there’s a wide variety of personalities.
You should, however, be detail-oriented and comfortable working with your hands, which means not being a massive klutz. Ophthalmology is a nuanced and delicate field, and those who appreciate the importance of precision are more likely to succeed.
Given the rapid rate of technological development in the field, you should also be willing to and hopefully even excited to use new technologies.
And finally, ophthalmology is more competitive than average, so you’ll need to be willing to work intelligently to position yourself favorably. That translates to more than just high board scores, but also playing the research game, being a leader, and crushing your clinical rotations beyond just surgery.
And who better to learn from and be mentored by than ophthalmologists themselves. Big shout out to Dr. Mundae and the other ophthalmologists from Med School Insiders that helped me in the creation of this post. If you need help acing your MCAT, USMLE, or other exams, our tutors can maximize your test-day performance. If you’re applying to medical school or ophthalmology residency, our ophthalmologists can share the ins and outs of what it takes and how to navigate the process most effectively.
Thank you all so much for reading! What specialty do you want me to cover next? Leave a comment down below.